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目的提高病案管理人员对冠名疾病名称编码的速度和准确率。方法运用计算机技术,建立数字化、电子化、智能化和人性化的操作模式,对二千多个以冠名疾病名称作全面的解释,将临床医学、医学基础理论与ICD-10结合起来开发了冠名疾病名称剖析检索系统。结果冠名疾病名称剖析检索系统内容丰富,操作简便,临床实用性强。结论冠名疾病名称剖析检索系统,弥补了国内这一系统的空白,提高了冠名疾病名称编码的速度及准确率,并可作为临床医生书写医疗文件的参考。
Objectives To improve the speed and accuracy of the case management personnel in coding the name of the disease. Methods Using computer technology to establish a digital, electronic, intelligent and user-friendly mode of operation, a comprehensive interpretation of the names of more than 2,000 patients with the name of the disease, the clinical medicine, basic theory of medicine and ICD-10 developed Named disease name analysis retrieval system. Results Named disease name analysis retrieval system is rich in content, easy to operate, clinical practicality. Conclusion The name-based disease name analysis and retrieval system has made up for the gaps in the domestic system, and has improved the speed and accuracy of coding the name of the disease, and can be used as a reference for clinicians to write medical documents.